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PERMITTEE NAME/ADDRESS (include Facility None/l.oornti n if Uiffiwat, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />GU U04u7 <br />iG I VEER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />MIN <br />(SU <br />1- - <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> <br />X OF <br /> E ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE 1 <br /> MEASUREMENT <br /> PERMIT <br />:... <br />M, <br /> REQUIREMENT +ai <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 7) U - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r.fii:;•v# r:?iF? >-. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t a : t t? a • : y is . <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> PERMIT ;. trtt t-+r ;:. # 1 > :? s 4 <br />- <br />17 r- 17 <br /> REQUIREMENT " ANN'VA . <br /> SAMPLE <br />M <br />T <br /> EASUREMEN <br /> PERMIT <br /> REQUIREMENT r' <br /> SAMPLE <br /> <br />MEASUREMENT _ <br />7 I <br />?r <br />C? 2 A 3 <br /> PERMIT <br /> REQUIREMENT ;i+; <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certih under penaih of low that thk document and all mtmitments wrrr <br />d <br />d <br />d TELEPHONE DATE <br />. \ prepare <br />un <br />er m% <br />irection or supervision in accordance with a .y.tem deigned 1 - <br />' <br />? <br />( <br />I ? <br />y -_ <br />1, <br />Crr to wwre that ynaiined personnel properiv pother and eraluate the information <br />' <br />Y ) <br />• <br />- <br />_ <br />C. <br />1 submfllavt. Nosed on m) inyuin o<tbe• pr•rwn ur per.oms In, mange the nTstem. <br />i or those persons directh m.gm%iW for gathering the information, the information <br />- <br /> <br />` submitted is• to the hest of m% kmoviedge and belief, trw% accurate. and complete. <br /> <br />I am aware that there are signincam penalties for suhmitting fake information. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />1 <br />TYPED OR PRINTED including the pos.ibiliq of rme and imprisonment for knowing sinintiom. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />ODE YEAR MO DAY <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. :tflZ63 ThisiB a 4-part fOml.